THE DEVASTATION
by MICHAEL SPECTER
Since 1965, life expectancy for Russian men has decreased by nearly six years. And now there is AIDS.
Issue of 2004-10-11
Posted 2004-10-04

The first days of spring are electrifying in St. Petersburg. The winters are hard and dark and long, and when the light finally returns each year thousands of people pour onto Nevsky Prospekt and into the squares in front of the Winter Palace and St. Isaac’s Cathedral. Petersburg has always been more open and more openly European than other Russian cities, and the day I arrived this spring was the first on which men in shirtsleeves could fling Frisbees across the endless avenues. I settled into one of the many coffee shops along the Neva River—they are a recent innovation—and noticed something else that was new: a large stack of pamphlets advertising an H.I.V. support group. aids is not a subject that people talk about much in Russia. Even though the epidemic is spreading here more rapidly than anywhere else in the world, there are virtually no public-service ads on television about it, and the government spends next to nothing on prevention, treatment, education, or care. This year, the entire budget for H.I.V.-related matters is a little more than five rubles per person, less than the cost of a pack of cigarettes.

St. Petersburg has been a rare exception to what seems like an official policy of ignorance and neglect. The city is responsible for the first program in Russia that sends buses to deliver information—and clean needles—to people who cannot be reached in other ways. It also pays for health workers to travel to schools, hospitals, and even construction sites to inform people about their choices. Condoms are available, and often free. Almost two years ago, St. Petersburg opened the country’s first aids hospice. There is still only one. Funded with local money, it sits not far from the city’s Botkin Infectious Disease Hospital, one of the largest such facilities in Russia. The hospice is small; it has just sixty beds, and they are not filled. The director, Olga Leonova, is a valiant woman with an impossible job: trying to assure patients that they have a future while convincing everyone else that aids threatens to turn Russia back into the Third World country it was before the Second World War. “You can see it getting worse every day,’’ she told me as we walked around the floor one morning. “It’s not just drug addicts now.’’ For years, H.I.V. infection in Russia was driven almost exclusively by shared needles. “We are seeing pregnant mothers and people we would never have even tested in the past.’’

Dr. Leonova is a middle-aged woman with chestnut hair and hazel eyes. She wore stylish striped pants under her lab coat, and her fingernails were painted gunmetal gray. She is proud of her ward, and enjoyed introducing patients. One of them, a frail boy with sandy-colored hair, had tried to kill himself, because he thought he had no hope of living. With drugs provided by the hospice, he would soon go home. Cases like his are common. “Most of our patients have nothing when they get here,” Dr. Leonova said. “They are dirty and hungry. The first thing we do is take their clothes and burn them.’’ We had returned to her office, and while we talked she stood at the window, staring at the birch trees. “I worry that aids will send us over the edge—that we will become a country too sick to cope. Most people don’t get it. Many of those who do understand have left. My five closest friends now live in the United States and Israel. My generation has no children. Husbands are dead. And now the young . . . ” Her voice trailed off. Dr. Leonova is an optimist, but she knows that the illness she encounters each day is a sign of an even larger problem—one that threatens Russia at least as seriously today as the Cold War did a generation ago. “We are on the front line of a war,” she said. “This city was under siege by Hitler for years. We lived through Stalin. We have to prevail, and I think, somehow, we will. We don’t have a choice.’’

From Tambov, the old Soviet breadbasket, to the Pacific port city of Vladivostok, and even in Moscow, which has become a world showcase for conspicuous displays of wealth, Russians are dying in numbers and at ages that seem impossible to believe. Heart disease, alcohol consumption, and tuberculosis are epidemic. So is addiction to nicotine. You won’t see many pregnant women on the streets; Russia has one of the lowest peacetime birth rates in modern history. Long life is one of the central characteristics of an advanced society; in Russia, men often die too young to collect a pension. In the United States, even during the Great Depression mortality rates continued to drop, and the same has been true for all other developed countries. Except Russia. In the past decade, life expectancy has fallen so drastically that a boy born in Russia today can expect to live just to the age of fifty-eight, younger than if he were born in Bangladesh. No other educated, industrialized nation ever has suffered such a prolonged, catastrophic growth in death rates.

In 1991, on the day the Soviet Union was dissolved, Russia’s population stood at a hundred and forty-nine million. Without the huge wave of immigration from the former Soviet republics which followed, the country would have lost nearly a million people each year since then. If Russia is lucky, by 2050 the population will have fallen by only a third, to a hundred million. That is the most optimistic government scenario. More realistic predictions suggest that the number will be closer to seventy-five or eighty million—a little more than half the current population. And none of these figures allow for the impact of aids, which remains, in many ways, unrecognized and unreckoned with. The World Bank has estimated that by 2020 at least five million people will be infected with H.I.V.; a more pessimistic, but equally plausible, figure is fourteen million. Even without aids as a factor, working-age people are starting to disappear. (In the United States, fifteen per cent of men die before they retire; in Russia, nearly fifty per cent die.) By 2015, the number of children under the age of fifteen will have fallen by a quarter. There will be at least five million fewer people in the workforce. The Russian Ministry of Education projects a thirty-per-cent drop in school enrollment. Russian women already bear scarcely more than half the number of children needed to maintain the current population, and the situation will soon get worse. Between 2010 and 2025, the number of women between twenty and twenty-nine—the primary childbearing years—will plummet from eleven and a half million to six million. Unless there is sudden new immigration on a gigantic scale, fertility will fall even from today’s anemic level.

A serious aids epidemic promises to compound each of these problems immensely: of all H.I.V. infections registered in Russia, ninety-nine per cent have been reported in the past five years, and sixty-five per cent in the past three years. Just at the time when the country will begin to reel under the burden of its shrinking labor force and an increasingly disabled population, it will have to find a way to cope with millions of aids patients, too.

The Russian government has recorded two hundred and ninety-two thousand people with H.I.V., but doctors and aids workers estimate that there are at least seven hundred and fifty thousand. Most epidemiologists, including those from the United Nations aids Program and the World Health Organization, believe that there may well be twice that number. Russia’s spotty system of medical accounting makes it impossible to know. People can be treated only in cities where they are “registered” as residents. Official statistics are based on cases—whoever walks through the clinic door. Yet millions of people live illegally in places where they cannot register—in Moscow, St. Petersburg, and other big cities—and so they are not counted and therefore cannot be helped.

“You can tell a politician that this country is going to vanish in twenty years if we don’t start dealing with the aids epidemic now, but they don’t listen,’’ Vadim Pokrovsky told me. Pokrovsky is in charge of the Russian Federal aids Center, in Moscow, and for two decades he has been the public face of Russia’s efforts to curtail the epidemic. “They only pay attention when people are dropping dead in the streets. That is going to happen. We can no longer pretend it won’t. It’s just a matter now of how many will die.’’ So far, that message has not sunk in. No senior Kremlin official was willing to discuss aids policies with me, because, as one explained, “we don’t have an aids policy to discuss. There is no plan, no goals, nothing. It’s not even on our radar.”

For most of its history, Russia has defined itself physically: as the biggest country on earth and as the place where Europe and Asia come together. Today, however, a nation’s significance is determined more by people than by land. Twenty-five years ago, the population of Russia was a hundred and forty million, and that of its neighbor Pakistan was eighty million. Within twenty years, that ratio will have reversed itself. If United Nations projections hold true, even Yemen will soon have more people than Russia. The prevailing view, initially, was that Russia’s sharp decline would be brief—a reflection of the chaos and uncertainty confronted in the nineteen-nineties by a new and deeply troubled society. But the trend actually began decades ago. In an era of antibiotics, molecular medicine, and universal literacy, the life of the average Russian man is almost six years shorter today than it was in 1965. Just fifteen years ago, the Soviet Union’s status as a superpower was unquestioned; today, the country is so weak that it is hard to see how it could ever regain that status.

Russia’s desperation seems to be driving the country in exactly the opposite direction. Last month, in the southern town of Beslan, Chechen separatists killed hundreds of children they had taken hostage at a school. Federal troops were given so little support during the siege that they had to borrow bullets from local civilians. The nation responded with shock, but President Vladimir Putin responded cynically: he seized greater power for himself.

More than military or political power, however, more than guns, revolutions, or monarchic decrees, demography is what has often shaped the relationships between countries. It was, after all, an unknown epidemic that wiped out a quarter of the Athenian army and at least as many of its citizens in 430-429 B.C. and helped end Athens’ reign as the capital of the world. Plague and cholera took tens of millions of lives, and played an essential role in creating the balance of power that existed in Europe for centuries. Even the size of China’s population can be attributed in part to its relative distance from epidemics that devastated other countries. The economic future of a sickly nation with a shrinking population cannot be bright. “Russian health statistics are so bad that we have all run them, many times,” Nicholas Eberstadt, a demographer at the American Enterprise Institute who has written widely on Russia’s health crisis, told me. “They never get better. The country just keeps going down—in numbers, in health, and in its possibilities for the future. It seems to get worse every year, and I don’t see even the slightest suggestion that that is going to change. Russia, like Africa, I am very sorry to say, is taking a detour from the rest of humanity as far as progress is measured by improving general health.’’

I made my first visit to Moscow in 1990, and a few years later I moved there. As a medical reporter for much of the previous decade, I had written about the emerging aids epidemic in the United States. In the nineteen-eighties, most Americans didn’t want to know about it. Even by the decade’s end, several years after Rock Hudson’s death—and not long before Magic Johnson’s infection set off a second wave of fear and anxiety—the governing sentiment was simple: only gay men and drug addicts got aids. The rest of us could safely turn our heads and shudder. Ronald Reagan was President for more than six years before he used the word in a speech. By that time, twenty thousand Americans had died and more than half a million were infected. It was already clear that H.I.V. would kill tens of millions of Africans. When I first visited Moscow, just as the Soviet Union was lurching toward its demise, I assumed that the Russians, with their new freedoms and openness, would have a problem much like ours.

That assumption was, of course, wrong. The Soviets hadn’t made their first aids death public until late in 1988, and the government seemed at least as interested in the fact that the St. Petersburg woman who died was a prostitute—with many foreign customers—as it was in exploring the medical consequences of her disease. Soon after her death, the official news agency, tass, reported that the woman had become a prostitute in the nineteen-seventies and had had many African clients. “An autopsy showed that she was four weeks pregnant, which indicates that she did not give up sex even at the extreme stage of the disease,”tass said at the time. aids was portrayed as the most ruinous manifestation of Western decadence. The Supreme Soviet had already introduced some of the strictest anti-aids laws in the world, among them a five-year prison term for infected people who knowingly exposed others to the disease.

The aids epidemic started slowly in Russia—for many years it was hard for foreigners to travel there—and by 1990 the Soviet authorities had registered fewer than five hundred cases, including dozens of children accidentally infected by physicians who repeatedly used contaminated syringes. Like nearly all Soviet (and Russian) health statistics, the number of those infected was no doubt a serious underestimate, based on the questionable system of case reporting. Yet Russia had been given a rare opportunity to learn from the mistakes of others, and to protect itself from a virus that has now infected at least sixty million people worldwide and killed a third of them—as many as the Black Death. “Because we were not part of the first wave of the epidemic, we were in a privileged position, with several years to prepare,” Vadim Pokrovsky told me at the time. Pokrovsky was then the chief of the Soviet Center for aids Epidemiology. He went on to say that the task of educating the public about aids and about sex was formidable. Infectious diseases don’t move forward in measured steps. They grow exponentially—and, in the case of aids, silently—gathering momentum until, as in countries from Haiti to South Africa, the epidemic becomes too forceful to stop.

By the end of the eighties, Mikhail Gorbachev had begun to turn the Soviet Union into a country where people were permitted to know the truths that governed their lives. The 1986 accident at the nuclear power station in Chernobyl forced the Soviets to introduce some degree of honesty into public affairs. After decades of official lies—about genetics, the environment, the health of the population, even about which way the rivers ought to run, and whether it was possible to reverse their course—the Kremlin had little choice. Pokrovsky told me in 1990 that he felt the country was ready to do what was needed, and, in fact, the press had begun to write frequently about H.I.V. While the absolute number of infections was low, however, Pokrovsky had no illusions that it would stay that way if the country did not act immediately.

Throughout the nineteen-nineties, though, aids seemed of secondary importance. Communism had been replaced by a sort of criminal capitalism; there was a war in Chechnya, and a stock-market crash and a subsequent economic implosion, and also epochal environmental and health problems. People were dying of stress, of heart attacks. Entire villages disappeared or turned into drunk tanks. Despite the lack of resources, Russian physicians are often vigorous, well trained, and imaginative. They did their best to cope with an endless stream of accident victims and the results of constant alcohol poisoning. There are better-equipped hospitals in Africa, however. I once stood in an operating room at the Semashko Emergency Hospital, in Tula, a city two hundred kilometres from Moscow, and watched as cancer surgeons removed a tumor from a woman’s chest. In the corner of the room, on the floor, sat the mechanism they used to sterilize their instruments: a twenty-five-dollar hot plate.

I went to see Pokrovsky recently, for the first time in years. He was holding a press conference in Moscow for a new aids initiative by the European Union. There are many efforts in Russia now to focus attention on the epidemic—from the E.U., from the United Nations aids Program, from American researchers, and from multinational relief organizations. The only groups that seem to be missing are Russian. Pokrovsky talked, as he often has, of an inevitable emergency that has the potential to destroy the country’s already fragile public-health network. He noted that Russia’s demographic crisis added special urgency to the task. Afterward, there were only a couple of desultory questions, and we adjourned to a nearby office. Pokrovsky is meticulous and soft-spoken, with a permanently sad smile on his broad face. His father, Dr. Valentin Pokrovsky, is the president of the Russian Academy of Medical Sciences. His mother is also a physician. They, too, have sounded alarms about aids, and they, too, have been ignored. Last year, the elder Pokrovsky appeared before the Duma to say that there may be at least a million and a half H.I.V.-positive Russians, and that in cities like Irkutsk and Samara at least one per cent of the adults were already infected. The speech changed nothing.

Pokrovsky finds himself saying today exactly what he said in 1990. “I never imagined we would have three hundred thousand H.I.V. infections,” he told me. “Fifteen years ago, I was certain we would see the scope of the problem and do what was necessary to stop it. And now I am in the position of saying to myself, ‘I am certain that we can prevent millions of infections in this country.’ But sometimes I wonder. Why am I certain? What has happened to give me confidence? And, really, the truth is we should all be afraid, because we have done very little here in Russia. If the situation does not improve, there will be at least five to seven million cases within fifteen to twenty years. Seven million people who are sick and dying of aids. And maybe many more. We will long ago have passed our ability to pay for treatment of any significance.’’ The Russian government hasn’t put much pressure on pharmaceutical companies; consequently, the country has some of the highest prices in the world for the antiretroviral drugs that have become the standard treatment for H.I.V. The U.N. aids Program has estimated that seventy thousand people in Russia need such treatment now, yet only fifteen hundred Russians actually receive the drugs, and almost all of them are in Moscow, by far the richest city.

“Our society doesn’t understand what it’s dealing with,” Pokrovsky continued. “It just isn’t ready. We spend a million dollars a year on awareness programs. We should be spending seventy million.’’

It isn’t easy to make the case that aids requires special attention in a nation besieged by other troubles. Countries like Kenya, China, and India are faced with so many fundamental challenges—starting with the need for clean water and the ability to prevent the most basic childhood diseases—that aids just seems like another in a long list of intractable maladies. “When you tell President Putin that we should spend more money on aids than on heart disease, which kills millions of our citizens now, he will ask why. And the answer—that it will kill a few million people in twenty years—is not going to be good enough for him.”

Putin is what the Russians call a poryadochny chelovek, a man of order and discipline. He has nearly total control of the government; the country remains a place where decisions flow from the top, and until the President makes aids an issue the apparatchiks who spend their lives trying to anticipate his desires are unlikely to do so, either. “This is the first country with a declining population that aids has hit in this way,’’ Steven Solnick, the Ford Foundation’s chief representative in Russia, told me. “And that changes everything. It makes the problem more urgent, of course, but in the Kremlin it creates a complicated political dynamic. aids gives the forces that are hostile to change a reason to enforce a conservative social order. It offers an excuse to complain about drug addiction, to stress conservative views on family values; it encourages people to consider placing restrictions on abortion.

“When Putin has mentioned aids, he has done so in the same breath as drug addiction,” Solnick went on. “He is just not a man who is going to go out there and say ‘We have a problem and we need help.’” On my way to Moscow, I had stopped in Geneva to visit Peter Piot, an unusually understated and diplomatic man, who is in charge of the U.N. aids Program. Neither Putin nor any of his deputies have been willing to meet with Piot, something that Presidents and Prime Ministers do nearly every week. “No country with this important an aids problem has done so little,’’ Piot said. “It’s my biggest nightmare.’’

John Tedstrom, who is the president of a new organization called Transatlantic Partners Against aids, told me when we met in Moscow that one of his goals was to persuade Putin to give a speech about aids. A few days later, the Kremlin asked him to provide some paragraphs for the President to include in his annual State of the Nation address. I ran into Tedstrom on the street near his office that afternoon and he was excited. When the speech was delivered, at the end of May, Putin never uttered the word “aids,” though he did find time to warn foreign human-rights organizations to stay out of Russia’s business.

It will be at least a decade before the full force of the epidemic is felt in Russia. The virus can take that long to destroy the immune system. Until then, a person can seem healthy and may even have no idea that he is about to die—and that is the case with hundreds of thousands of Russians today. By 2010, many of them will need daily antiretroviral treatment.

According to Russia’s Federal aids Center, last year the number of H.I.V. infections actually fell by some twenty-five per cent, but that is partly because the central government has stopped supplying H.I.V.-test kits to Russian regions; many local governments simply can’t afford to buy them, so fewer people are tested. “We have been trying to identify what office in the Ministry of Health is responsible for aids,” Marina Semenchenko, the doctor in charge of the World Health Organization’s aids efforts in Russia, told me. “There is no one.’’

Evidence that aids is spreading into the wider population is overwhelming. As recently as 2000, ninety-six per cent of officially registered new cases were attributed to intravenous drug use. By 2002, the number had fallen to seventy-six per cent. Last year, it fell again, to sixty-four per cent. The male-to-female ratio of infection also began to shift in 2002, and there was a two-hundred-and-thirty-per-cent increase in the number of babies born to H.I.V.-infected mothers. There has been yet another ominous sign: the rising rate of syphilis infections, which has proved to be an infallible barometer for the incidence of H.I.V. Greece reported no syphilis infections in 2001; the Netherlands reported less than one case per hundred thousand people; Turkey had five cases per hundred thousand; Iceland had just over eleven. Russia, however, had a hundred and forty-four cases. The H.I.V. epidemic passes a critical boundary when one per cent of adults become infected; that figure has turned out to be a sort of trip wire. After that, the virus becomes much more difficult to contain. In many parts of Russia, that one-per-cent figure has now been reached.

In the middle of April, I flew to Irkutsk, just in time for the last snowstorm of the season. Within a couple of hours, several inches were on the ground; then, almost as quickly, the snow disappeared, blown away in gusts. The city, sixty-five kilometres from the shores of Lake Baikal, was dark, cold, and uninviting. Baikal is the spiritual home of modern Russian nationalism and the emotional center of Siberia; during the Soviet era, a group of writers from the region emerged as almost accepted voices of protest. They never criticized the Kremlin directly, but by focussing on the land—the natural, mystical beauty of historic Russia—they were able to implicitly criticize the regime’s disregard for the people. Irkutsk is not industrial or academic, like Novosibirsk; it’s a one-horse town that just grew. The city has its share of oppressively monumental Soviet architecture—memorials to fallen soldiers of the motherland, the stolid headquarters of the Communist Party (now the administration offices for the regional government), and scores of the cinder-block housing projects that helped make residential life in the Soviet Union such a numbing experience. But even Stalin couldn’t fully erase the wildness of Siberia, and one can still find some of the original wooden houses that were erected when Nicholas I exiled the Decembrists from St. Petersburg, in the nineteenth century. Many of the houses are falling apart—they tend to sink deeper into the ground with every spring thaw. But they bolster the city’s image as a sort of frontier outpost between the European part of Russia and the wilds to the east.

For centuries, Irkutsk has been one of Siberia’s most important trading centers, with merchandise moving constantly along the routes between China and Russia. Now, because it has become a convenient transit point for heroin from Afghanistan, the aids problem has become more urgent than in most other Russian cities. Drugs have flooded the streets since the late nineties, and these days you can buy a dose of heroin for a hundred rubles, or about three and a half dollars—an attractive offer in a city full of unemployed young people with little prospect of a future. Between 1991 and 1998, health officials in the Irkutsk region registered fewer than fifty people infected with H.I.V. By the spring of 1999, a state of emergency had been declared. Doctors diagnosed dozens of new infections every day. Last year, the region, with two per cent of the Russian population, registered more than twenty per cent of the children born to H.I.V.-positive mothers.

There is information about aids available in Irkutsk, but nobody seems to know where to find it. You certainly don’t see public-service announcements on state-run television or hear them on the radio. I never noticed a billboard or read a newspaper advertisement. (For that matter, newspapers and magazines have largely stopped writing about aids, too.) Nobody hands out pamphlets or canvasses night clubs or explains the risks to schoolchildren. Not surprisingly, since very few people have actually fallen ill, fear is limited. “Sometimes I think I don’t know anybody who isn’t using or hasn’t used heroin,” a young H.I.V.-positive woman named Sveta told me one afternoon at the local Red Cross drop-in center. Sveta is twenty-two, with long reddish-brown hair. The day we met, she was wearing a short leather jacket and green corduroy pants. She had a gold wedding band on her left hand and a large green ring on her right. Sveta has a three-year-old son, Simyon, and she told me that she had tried heroin a few times with a friend, out of boredom. She said that her husband was not infected and that they were both unemployed. “I didn’t know you couldn’t share needles,” she told me. “It just seemed like the obvious thing to do.’’ She said that she was grateful that her son is not infected, but that she took no particular precautions. “I was lucky,” she said. “Most of the people don’t care about their health. They just want drugs. Well, there are no jobs here. Nothing much to do, and there are lots of drugs. If you go to school, you have to pay in order to pass your exams. I finished school, but who wants me? To get a job in a shop, you have to bribe somebody or pay them part of your wages. So that means I can work in a kiosk on the street.’’ Sveta comes into the city from a village about an hour away to see a psychologist whom the Red Cross makes available for counselling. “I have a lot down inside of me, and it’s good to talk to somebody,’’ she said.

We were sitting in the tiny office of the drop-in center, in a muddy courtyard off Karl Marx Street. The Red Cross was the only organization in Irkutsk that seemed to understand the seriousness of the threat posed by H.I.V. Everywhere else, I encountered willful blindness and almost complete denial. “Every tenth person in Russia believes that aids doesn’t exist,” Marina Akulova, the leader of the Irkutsk Red Cross, told me when I asked about the attitude. “Another ten per cent believe it can’t possibly affect them.’’

I was even told, by Aleksandr Goliusov, of the Ministry of Health, that the infection rate in Russia wasn’t nearly as bad as Western experts have asserted, and he implied that the West was simply trying to humiliate Russia by inflating the figures and comparing them to Africa’s. He was not the only person to say this to me. “Isn’t much of this coming from your C.I.A.?’’ he asked, with some justification. The American intelligence community has for several years been openly concerned about the security threat that a rampant epidemic in Russia would pose; it is hardly a controversial assessment, though, since Russia maintains an enormous arsenal of nuclear weapons. “I can only work with the numbers we have,’’ Goliusov said. “We receive requests for service and medication based on those numbers. The C.I.A. has issued a report saying that from three to five million people are infected with H.I.V. in Russia. That simply is ridiculous. I can agree that not every case is reported or counted properly. But the number that foreign observers say need medicine now is fifty thousand. That is just wrong. What the international organizations do is they apply mathematical models, and they said if there are seven hundred and fifty thousand infected you should have fifty thousand who are sick. But that is theory, and reality is what I get coming into hospitals and clinics.’’

Russia is one of the world’s best-educated nations—the literacy rate is above ninety-nine per cent. But, in a poll conducted last year, two-thirds of the respondents who knew that aids is caused by H.I.V. also believed that it can be contracted through kissing; a majority of Russians think you can get aids from a cough; and three-quarters believe that the virus can be transmitted by mosquitoes. None of that, of course, is true. While I was in Moscow, two acquaintances of mine—both successful professionals with access to people at the highest levels of the Kremlin and of Russian life—were astonished to learn that it takes many years for a person to become sick after being infected with H.I.V. That the virus goes about its business silently, destroying the human immune system without warning, is one of its defining characteristics. If there were no time lag between infection and illness, aids would not have been so insidious, and so difficult to understand. One Russian woman I have known for years, a prominent liberal, said, “aids might be a good thing, in a way, because it is killing people who only destroy the country anyway.’’

She was talking about drug addicts. The Russian government has been particularly unwilling to treat substance abusers as citizens in need of help instead of as criminals. A highly critical report by Human Rights Watch noted earlier this year that H.I.V.-infected addicts are often barred from the type of education and outreach programs designed to help them. Even in prison, which itself is a notorious incubator for H.I.V. and for tuberculosis, inmates rarely have access to treatment. The report argues persuasively that the government has made the epidemic far worse by routinely mistreating and victimizing those who are infected. The attitude toward drug use is so uniformly harsh that the people at the Red Cross in Irkutsk were reluctant to send me into neighborhoods where heroin is bought and sold. They consider it dangerous, and, one of them told me honestly, the city has been receiving bad publicity. Nonetheless, I was introduced to Misha and Alyosha, both former heroin addicts in their thirties who travel frequently to Trety Posyolok, the neighborhood where heroin is sold openly. They were willing to let me tag along when they delivered clean needles to a friend who distributes them there.

We flagged a taxi. The driver raised an eyebrow when he heard the destination. But money is money, so he nodded and we piled in. As we talked, the driver immediately jumped into the conversation. “One day,” he said, “I had a guy come in and he wanted to buy drugs. So I said O.K. and I took him up the hill.’’ The driver fell silent, then continued, “He went into a house to buy his stuff and then he came out, and before I could say a word he had a needle in his arm and he was shooting up in my taxi.” This was a couple of years ago, he recalled, at a time when the heroin sweeping into the area was particularly potent. The passenger overdosed and started to choke. “He was dying right in the back of my car,’’ he said. “I had to rush him to the hospital and explain what happened. I am lucky they didn’t throw me in jail.’’ We asked if the man had lived. “I don’t know,’’ the driver said. It was clear that he didn’t care. We drove across the Angara River, and soon we passed a line of cabs. “Heroin taxis,” he said. “These are the cars willing to take people to Trety Posyolok.” He told us that most cabs didn’t want to bother, and that since his near-death incident a couple of years earlier he hadn’t been back.

Trety Posyolok is not much more than a collection of wooden houses, muddy, half-paved roads, and seedy kiosks scattered along the southern edge of Irkutsk. The Posyolok—the word means “settlement”—is part of the city now, but it was created in the nineteen-sixties as a separate village, the third in a row of identical places all thrown together to house workers assigned to build the power station that still dominates the area. Few of the streets have names. Almost everyone who ventures there knows where he is going and why: it’s the best place in the city to buy heroin and to pick up a fresh dvoushka, one of the two-millimetre syringes favored by Irkutsk drug addicts.

We drove down a narrow, shabby street. Garbage was strewn everywhere. Gypsy touts and homeless women stood on the corners rubbing their hands together to keep from freezing. The moment we parked, a toothless man wearing a Los Angeles Lakers sweatshirt approached. “You want it?’’ he asked. “A hundred rubles. Very clean.” Drug deals are done both on the streets and in the houses. Each location has its dangers; the main street leads to a hill, and at its end is the regional police academy. We watched as, every few minutes, fresh-faced recruits, none more than eighteen years old, walked awkwardly down the hill, guns strapped tightly to their hips, as they pretended not to see what was happening all around them. Misha and Alyosha took me to a rickety old house halfway up the street. Two large but seemingly docile dogs responded to the doorbell. They were quickly followed by their owner, a thin, hawk-faced man with a ponytail and a cigarette dangling from his lips. The man’s name was Volodya, and he is the most effective preventive weapon against aids in the neighborhood, because each week he hands out clean needles to anyone who asks.

Distributing clean needles occupies a gray area in Russian law. Most people assume that it encourages drug use, and many officials oppose it for that reason. (In fact, the participants in a major aids conference held in St. Petersburg this May took a stand against distributing clean needles.) In some cities, including St. Petersburg and Irkutsk, aids organizations have made efforts to explain to the police why they are beneficial. Volodya says that he isn’t hassled much anymore, though police in Irkutsk are certainly not eager to talk about their approach to needle exchange or narcotics. (I tried to meet with narcotics-squad officers while I was there. They told me that they could speak only with the permission of Moscow, which I had not obtained. I then called the head of the local police. He also refused to see me.) Volodya was hardly surprised to hear this. “All we have to do is pay some bribes,’’ he said with a shrug. “Sometimes it’s just give them condoms and other times money. But if people come to my house to get needles and they have drugs they can be busted, and so can I.’’ There was a knock on the door. Two men stood silently on the stoop. Volodya pulled out a shoebox full of neatly packaged two-millimetre syringes. Then he took a few individually wrapped alcohol swabs from his pocket. The men took them, nodded sullenly, and were gone. The entire transaction lasted less than thirty seconds.

Volodya has used drugs for years, but his main interest in life is heavy-metal music. He has nearly a thousand records, and he plays them day and night. He showed me the cover of the album that was currently rattling the windows of the house, “1000 Percent Metal Ballads.’’ He talked at great length about the relative merits of Metallica, Megadeth, and Aerosmith before mentioning that he had travelled to Moscow in 1995 to see a performance by Deep Purple—his favorite group by far. “It was worth every minute and all the costs,’’ he said with a smile of the deepest possible satisfaction.

Volodya is available all day to pass out clean needles to anyone who knocks. “Why?” I asked, waving away a thick cloud of cigarette smoke. “Clearly, it’s dangerous. Why bother?”

He looked mystified. “I can deal with the police,” he said. “I have lots of friends, they all use drugs, and I would like them to stay alive.’’

The next afternoon, I drove to the Irkutsk Infectious Disease Hospital. The complex is far from the center of the city and is difficult to reach. It was nearly deserted. Every significant city in Russia has an aids center. Moscow’s is a crumbling shack situated near the back of the Second Hospital for Infectious Diseases, the main hospital for H.I.V. in the capital. It was marked by a small plaque. Irkutsk’s center was in better shape, but it is tucked away on the grounds of the hospital complex, behind a large building, and is marked by the smallest imaginable sign, written in white paint on the side of a red brick building that almost nobody ever sees. The writing looks like graffiti (except that nobody writes graffiti that small): “Tsentr spid”—spid being the Russian acronym for aids. I had come to see the chief of the region’s aids unit, Dr. Boris Tsvetkov. He was a pleasant middle-aged man, and he welcomed me with the type of hospitality that was common among mid-level Soviet officials: he made tea, took a box of chocolates from his desk, tore off the cellophane, and insisted that I eat.

Tsvetkov told me that the severity of the problem in Irkutsk was often exaggerated. “All the responsible parties, from the police to health organizations, work together to fight the virus,” he said. “We coöperate.” I asked why the police refused to talk about the relationship between drug use and aids. He shrugged. “That’s a difficult issue,’’ he said, but he would not elaborate. He acknowledged that in Irkutsk, as in many other parts of Russia, a fundamental shift is now under way, with the epidemic moving from its base among drug users to people who are infected through heterosexual contact. Statistics are collected in a haphazard way, but they tell a story that isn’t hard to understand: in 1999, more than ninety per cent of those who tested positive for H.I.V. in the region were intravenous drug users. Today, that number is sixty-five per cent. “And I know that we are able to catch at most only half of the infected people,’’ Tsvetkov said. He added that doctors were treating fewer than two dozen people in the region with antiretroviral drugs. “It just hasn’t become that big an issue yet,’’ he said. I asked how, in a city of more than half a million, with one of the country’s highest aids-case rates, there could be so few people on antiretroviral drugs. “We treat those who come to us with the appropriate diagnoses,” Tsvetkov said. “The number right now is sixteen. I know that it will change soon and that we’ll need money from the government. But in the last two years the number of infections has gone down.’’ He shrugged. “It’s meant that it has been hard to get money from the central government. There is a feeling in many places that the problem is going away. We know very well that is not true.” He said he was aware that Irkutsk was gaining a reputation as a center of the aids epidemic in Russia. He was not pleased. “We do acknowledge the problem,” he went on. “Still, we are experiencing nothing more and nothing less than what the rest of the country experiences. It’s not easy now, and it’s only going to get harder. In two or three years, I know, it will take our entire health budget just to treat people for H.I.V. And when that happens I am not sure, really, what we are going to do.’’

The man who for decades has paid the closest attention to the Russian population crisis is not even Russian; his name is Murray Feshbach, and he works in Washington, D.C. Feshbach, a scholar of Russia, statistics, and lies, started telling people in the nineteen-seventies that the Soviet Union was so frail that it was in danger of falling apart. Nobody wanted to listen. The Soviets lied about health statistics, and during the Cold War few American leaders were willing to believe that their mighty adversary in the great battle for ideological and physical supremacy could actually be sickly and weak. But Feshbach—first while working for the U.S. Census Bureau, then as a professor at Georgetown University, and now as a senior scholar at the Woodrow Wilson International Center—has spent his life plowing through obscure data in otherwise unread files. He has never wavered from his view that disease and the effects of environmental poisons are the biggest threats that Russia faces. His books—“Ecocide in the U.S.S.R.,’’ about the horrendous environmental damage done by the Soviets, and a recent volume on Russia’s demographic crisis—are impossibly grim. Eventually, though, American leaders, and then many of the Russians who had once mocked him, began to admit that Feshbach was right.

I went to see him one day not long ago, just a week before he was scheduled to fly to St. Petersburg, where he was to receive an award for his work. Feshbach is a heavy man with thick glasses who looks like an owl and seems to possess a copy of every number or population statistic that exists. His workspace at the Wilson Center was strewn with arcane monographs, charts, and books like “Infections and Inequalities: The Modern Plagues,” “Pathologies of Power,” and “The Wellbeing of Nations.” There were stacks of data sitting on his desk and a pile of the articles and studies that he was most interested in at the moment; they ranged from the demographics of Bulgaria to the economic impact of sexually transmitted diseases in Central Asia.

“What do you think it’s going to take before Russia starts to respond to aids seriously?’’ he asked me, then quickly answered his own question. “More deaths. Many more deaths. Not enough have died yet.” He began to recite statistics. “The demographic is moving, it’s moving right now,’’ he said, meaning that the epidemic was switching from one primarily among drug users to one with a significant base in the wider population. “You can see it in pregnant women. As officially recorded, the number of infected children born to women who were not drug users is seventy-five hundred. But seventy-five per cent of them were born in the past two years.’’ The military will be hit particularly hard. Although the Russian government has said that it intends to maintain armed forces of a million men for many more years, it is unlikely to succeed. After 2005, the number of seventeen- and eighteen-year-olds eligible for military duty will decline sharply, the result of the baby bust of the late nineteen-eighties and early nineties. Soldiers are at much higher risk for H.I.V. than other members of society: young men are prone to risky sexual behavior, often relying upon prostitutes during long tours of duty away from home, and drug use is common. In 2002, only eleven per cent of the men called to serve were considered fit for duty; five thousand draftees tested positive for H.I.V. and were turned away. In fact, in the past five years the number of draftees with H.I.V. has increased twenty-five-fold. Last year, a quarter of those who entered the armed services during the spring draft had less than nine years of education, which means that they could not be trained to use the advanced equipment that is central to the success of a modern army.

“The military is a complete disaster area—prosto koshmar,’’ Feshbach said, using the Russian words that mean “simply a nightmare.” Russian defense planners have even floated the idea of creating a foreign legion for Russia. In the coming decade, it may be the only way to maintain the Army. “The situation is awful, horrendous, terrifying—any word you want to use,” Feshbach said. “Russia badly wants a modern military, but you have to have a certain skill level to do something more than just run and stop and shoot. And when there are fewer soldiers what will the generals rely on?” Shaking his head, he answered the question. “Nuclear weapons, biological weapons, and chemical weapons,” he said. “That is what scares me the most. Russia has a view of itself as a superpower, and this is the only way it can support that view. The country can only become more unstable as it becomes sicker, but its leaders cling to their view of Russia as it existed when there was a Soviet Union. They want to be compared with us, not with Ghana. aids will not permit them to do that much longer. This epidemic will alter the way families are formed, and change the labor force completely, not to mention the way cities are built and populated.’’ Feshbach added, “It’s going to be an epochal reshaping of that part of the world.’’

As the number of people in the working population shrinks, so, naturally, will the gross domestic product. Russia may lose as much as eight per cent of its annual income, but experience from other countries demonstrates that the repercussions from H.I.V. are far larger than what one would expect simply by subtracting the money earned by those who are sick. People have to be fed, clothed, and taken care of, and that hurts productivity as well. If your best friend is dying of H.I.V., you are less likely to concentrate at the workplace and less likely to volunteer for the night shift, and, more than that, if your son or mother is dying you don’t go to work at all. aids also changes the way a society thinks. In most countries, the principle of saving is easy to understand: if you put money aside today, somebody will use that money to produce shoes or a computer or to build a house tomorrow. In Russia, people will die too soon to take advantage of any of that, so they are not likely to consider investment or saving for the future to be worth the effort. In countries where aids has taken a large toll, people quickly learn to consume what they have. The savings rate plummets, and the economy suffers badly.

“I think Russia will get desperate,’’ Feshbach said. “People will eventually see where they are going, and they will get desperate. There are people who say Russia will die. I don’t know. But it will be weak and unstable. How can it not? Right now, the state is doing nothing, and if the state doesn’t address this basic problem what does it address? I have heard every excuse for the lack of initiative: fate, that the Russians don’t care if they live or die, that they don’t understand life, that aids is too much of a stigma. I have heard that it’s just about these promiscuous people, that it’s bad stuff coming from the West, that it’s the wrong crowd.” He concluded, “Who cares what the reason is? Who cares? What is happening in Russia right now is going to define, to a large degree, the future of the aids epidemic globally. Yes, the country escaped for twenty years, but now it is confronted with possibly a disaster. And the impact, the size of the population, and the geography mean that it will have a direct influence on what will happen in Europe, in Central Asia, even in China and India. And that will have an impact on us. It’s hard to imagine a more critical country at a more critical moment.”

How many fact-finding tours of southern Africa, of India, and of various countries in Eastern Europe will Russian officials take before they see the implications of the epidemic that is now spreading rapidly within their borders? Why does Brazil, with a comparable population and a slightly lower per-capita income, spend nearly a billion dollars on aids each year when Russia doesn’t spend even a tenth that? It can’t be poverty; Russia is not rich, but it has eighty-five billion dollars in its financial reserves. The Kremlin is certainly capable of spending money when it wants to: last year, for example, the lavish three-hundredth-birthday party for the city of St. Petersburg—Vladimir Putin’s home town—cost $1.3 billion. There are more billionaires in Russia today than in any other country—at times, they seem to be buying everything that is not nailed to the ground, from yachts and British soccer clubs to Malcolm Forbes’s collection of Fabergé eggs. “Do you think for one minute that if Putin called these people into a room and said we have a crisis and we need to come up with some money for aids they would say no?’’ a senior international health official asked me. “Do you think that anyone in Russia can begin to justify spending just a few million dollars on aids each year? There are people there who spend that maintaining their private jets.”

The Kremlin demands to be taken seriously as a world power and as an active member of the Group of Eight industrial nations. The country’s leaders often mention aids in public at international gatherings, acting as if Russia still had an empire to control. At home, though, the story is different. “Russia went ahead and made a decision to contribute money to the Global Fund,’’ Christof Rühl, who was until recently the World Bank’s chief economist in Russia, told me. The Global Fund to Fight aids was set up by the U.N. to provide money for those countries which cannot on their own defeat aids, tuberculosis, or malaria. I talked to Rühl one day when I was in Moscow. He was taking a break from a conference on Western investment, held at the Radisson SAS Slavyanskaya Hotel. Men in Valentino suits were talking on cell phones and smoking huge cigars. Their drivers and bodyguards, all clad in thick black leather, stood smoking cigarettes patiently by the coatroom.

Russia invested just over four million dollars in 2003 in its federal aids program, but it committed twenty million to the Global Fund to Fight aids. Two years ago, the Kremlin’s protracted negotiations effectively delayed a hundred-and-fifty-million-dollar loan offer by the World Bank on the ground that it did not wish to incur further foreign debt. “If you watch,” Rühl said, “you will see the President and all the ministers and the economic advisers going out and saying to the world, with great pride, ‘Russia is a donor country. We are one of you. We are going to help solve this health crisis for these poor nations.’ It is cheap and cynical. It has not been about H.I.V. at all. It was to say, ‘We are a country that helps; we don’t need handouts, like Africa.’ But the truth is that the government is so disorganized and so removed from the needs of its own people that it could not even help get one application filed for the first round of this Global Fund.

“The people just don’t care. On a very broad scale, it’s a country where people care about their family and their friends. Their clan. But not their society. Yet they have this attitude that we are a great power. A donor nation. What does that really mean? It means you pay a few million dollars to the world aids fund even though you are too stupid to attempt to profit from it when your own citizens are dying.’’